Breaking Down Barriers Innovations in Cross-Border Harm Reduction Between Yunnan Province, China and Burma (Myanmar)

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Breaking Down Barriers Innovations in cross-border harm reduction between Yunnan Province, China and Burma (Myanmar)

A HAARP Positive Practice Study: In collaboration with Yunnan Provincial HIV/AIDS Prevention and Control Bureau and Yunnan Public Health Bureau Acknowledgements

This Positive Practice study was commissioned by the HIV/AIDS Asia Regional Program (HAARP) Technical Support Unit in Bangkok and was drafted by Corrie Mills. © Commonwealth of Australia 2011 We would like to thank all in the Yunnan Injecting Drug User Cross-Border This work is copyright. Apart from any use as permitted under the Harm Reduction Project (Yunnan Cross-Border Project) and the Ruili AIDS Copyright Act 1968 no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and Department for their support and hospitality while researching this study. inquiries concerning reproduction and rights should be addressed We would also like to acknowledge all those who helped produce this to the Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 document: Duo Lin, HAARP Yunnan Manager; Zhang Miaoyun, Chief of the or posted at Ruili AIDS Department; Han Shuaizhan, Qiu Zhengxian and Mao Chunling, www.ag.gov.au/cca Ruili outreach workers; Li Hong, Director of the Education and Science

Department, Yunnan Center for Disease Control and Prevention; Zhou This document is online at: www.ausaid.gov.au/publications For more information about the Australian Government’s international Hongmei, Deputy Director, Administration Office of the Yunnan Provincial development program, contact: HIV/AIDS Prevention & Control Bureau; Michael Cole, Australian Agency for International Development; Mukta Sharma, HAARP Technical Support Unit; Communications Section and Ji Xue, Project Officer, Yunnan Injecting Drug User Cross-Border Harm AusAID GPO Box 887 Reduction Project. Canberra ACT 2601 Australia Phone +61 2 6206 4000 Facsimile +61 2 6206 4880 Internet www.ausaid.gov.au

Edited and designed by Inís Communication www.iniscommunication.com Contents

Acknowledgements ii

Abbreviations iv

1. Introduction 1

2. Background 2

3. Key achievements to date 3

3.1 Rapid setup 3

3.2 Sustainability 4

3.3 Generating strategic information 4

3.4 Cross-border cooperation 4

4. The Yunnan Cross-Border Project in action 6

4.1 Cross-border capacity building 6

4.2 Cross-border research and strategic information 8

4.3 Cross-border service provision 9 5. Challenges and areas for improvement 12 Abbreviations 5.1 Equal participation 12

5.2 Improvements in service delivery and referral 12

5.3 Emphasis on the local context 12 AIDS acquired immunodeficiency syndrome

5.4 Gender awareness 12 ARHP Asia Regional HIV and AIDS Project

5.5 Selecting and training outreach workers 12 EAP effective approach project HAARP HIV and AIDS Asia Regional Program 6. Lessons learned and best practice in cross-border working 13 HIV human immunodeficiency virus 6.1 Using regional programs to facilitate cross-border work 13 IEC information, education and communication 6.2 Importance of flexibility 13 MMT methadone maintenance treatment 6.3 Importance of strong local knowledge 13 NSP needle and syringe program 6.4 Need for advocacy and education first 14 TSU Technical Support Unit 6.5 Research into practice 14

6.6 Politics and security 14 1. Introduction Box 1. Innovations in Ruili County

• Doubling up – making use of existing services and facilities to shorten setup time and reduce costs. “Before, the idea was to create a wall to stop HIV, but now we are cooperating as if we were one big region. Yunnan has shifted its policy from one-sided • Sustainability – strengthened through reduced costs of efforts to try to stop the disease to encouraging border counties to build using existing staff and services, and county government relations with the other side.” support • Results that push for policy change – producing and Zhou Hongmei, Yunnan Provincial Bureau of HIV/AIDS Prevention and Control sharing data to better understand the nature of the epidemic This case study was commissioned by the Australian Agency for International and by monitoring the outcomes of harm reduction Development’s Technical Support Unit (TSU) HIV/AIDS Asia Regional Program interventions to demonstrate what works in practice. (HAARP) to identify achievements and lessons learned from the Yunnan • Flexibility – helps address gaps in service provision and Injecting Drug User Cross-Border Harm Reduction Project (Yunnan Cross- respond to shifts in local and national policy and in the Border Project) on China’s borders with Burma (Myanmar) and Vietnam. epidemic itself. • Involving the private sector – Ruili AIDS Department’s Operating for only one year, the project has been noted for its rapid setup promotion of the active participation of all sectors of society. and quick gains in coverage. As part of the HAARP Positive Practice series, the Its cross-border project has used outreach workers who are purpose of this study was to investigate the mechanisms and strategies used not drug users, including doctors and local business people by project staff, as well as any potential to replicate them in other settings. such as language school teachers and shopkeepers. The study focuses on cross-border activities taking place between Ruili County in Yunnan Province and its Burmese neighbour, Muse. This site was selected for its innovative approach to cross-border cooperation and service provision. In addition, the study takes into account the strategic information and guidance provided at the national and provincial level, which has created a supportive framework for cross-border activities.

1 users cross to Burma (Myanmar) to buy cheaper drugs and Burmese 2. Background drug users cross to China to find work.

The Yunnan Cross-Border Project seeks to address the HIV epidemic on both sides of the border by: The Yunnan Cross-Border Project began on 1 November 2009, following • establishing coordination mechanisms for cross-border cooperation the Yunnan Provincial AIDS Bureau’s successful tender for Round One HAARP cross-border funding. Its aim is to control the spread • responding to the epidemic on both sides of the border with services of HIV among drug users and their partners along Yunnan Province’s for drug users and capacity building for local service providers international borders with Burma (Myanmar) and Vietnam by supporting • gathering strategic information to increase limited research into and effective harm reduction interventions. knowledge of effective cross-border programming.

In southwestern China, Yunnan shares over 4000 kilometres of Set-up of the cross-border project has benefited from the existing international border with Burma (Myanmar), Laos and Vietnam, placing HAARP project management team in the Yunnan Provincial HIV/AIDS it at the doorstep of the ‘golden triangle’ of heroin production. In 1989, Prevention & Control Bureau. The team was first established under the the first case of HIV in China was detected in Yunnan’s Ruili County. Asia Regional HIV/ AIDS Program (ARHP), 2000–2007 and was later To date, the province has one of the highest HIV prevalence rates in scaled up from four project sites to HAARP’s current 19 sites. China. Prevalence in China is considerably higher among people who Three sites have been set up along the Burmese border (Ruili/Muse, inject drugs: 9.3% in 2009 compared with an overall prevalence of 0.1%.1 Yinjiang/Kachin State and Longchuan/Lwejie) and one on the Vietnamese Yunnan is estimated to have 23 000 drug users in its border areas, or border (Hekou/Lau Cai). Of these four, Ruili/Muse is notable as the only 27.1% of the provincial total.2 one that already had HAARP project sites established on both sides of Yunnan’s HIV epidemic is compounded by those of its neighbours. In the border. 2009, HIV prevalence among injecting drug users was 18.4% in Vietnam The Yunnan Cross-Border Project in Ruili County brings together the and 36.3% in Burma (Myanmar).3 In many places, there are no clear border Ruili AIDS Department with the HAARP Effective Approach Project barriers, and the number of daily crossings between countries is high. (EAP) site in Muse, Burma (Myanmar). Ruili County had already begun People who inject drugs frequently cross the border, as Chinese drug some cross-border work ahead of the project, inviting a Burmese study tour in 2008 and establishing a drop-in centre for Burmese truck drivers 1 UNAIDS 2010 – http://www.unaids.org/en/regionscountries/countries/china/ [Accessed just across the border in Ruili City. HAARP’s cross-border funding has 02/02/11] 2 Yunnan Provincial HIV/AIDS Prevention and Control Bureau 2010, Cross border report afforded the Ruili AIDS Department the opportunity to expand its (November), [Kunming, China] activities and has further encouraged creative intervention. 3 UNAIDS 2010 2 3. Key achievements to date

3.1 Rapid setup The greatest achievement of the Yunnan Cross-Border Project is undoubtedly the speed with which it began operating. Some needle and syringe program (NSP) sites, notably in Ruili County, were established in November 2009, the same month that the contract was signed with the TSU. At the end of one year, the project reached 1248 Burmese and Vietnamese clients.

Achievement indicators of the Yunnan Cross Border Project, 2010

Item (number) Hekou Longchuan Ruili Yinjiang Total Information, education and communication materials distributed 94 1537 417 217 2265 Condoms distributed 618 7372 2370 6268 16 628 Needles/syringes distributed 11 613 66 331 80 953 120 144 279 041 Needles/syringes collected 10 012 61 814 75 520 93 417 240 763 Referrals made 0 92 28 48 168 Contacts made with Vietnamese or Burmese clients 1544 15 764 23 735 11 855 52 898 Vietnamese or Burmese clients 113 279 591 265 1248 Vietnamese or Burmese clients (male) 92 275 581 216 1164 Vietnamese or Burmese clients (female) 21 4 10 49 84 Contacts made with Chinese clients 245 1560 32 445 2282 Chinese clients 64 77 17 166 324 Chinese clients (male) 49 77 17 163 306 Chinese clients (female) 15 0 0 3 18

3 In the last year, Ruili County achieved impressive coverage. In addition project’s fast setup but has also reduced costs by using resources that to the figures above, 96 Burmese drug users are now on methadone are already available. Furthermore, by locating services in existing sites maintenance therapy (MMT) and harm reduction training has been held the Ruili team has ensured that infrastructure and personnel will remain for 345 Chinese and 400 Burmese people in Ruili’s detoxification centre. after project funding ends.

From the beginning, existing HAARP infrastructure helped to accelerate In addition to the project’s focus on sustainability, commitments have project establishment. When submitting the cross-border project been made at the local, provincial and national level to continue cross- proposal, the provincial team was able to garner approvals from county, border work. Provincial funding has been announced for carrying out provincial and national governments by capitalising on existing program baseline studies among target populations living in 25 counties along arrangements and relationships. The provincial team managed to get the the border. proposal signed off at all levels within 20 days, and it is unlikely that such 3.3 Generating strategic information a rapid approval would have been achieved by an entirely new project or a nongovernment organisation. Similarly, the rapid establishment of One unexpected result of the Yunnan Cross-Border Project has been cross-border interventions in Ruili County can be credited in part to the large amount of data generated and researched by the provincial the team’s existing relationship with the HAARP project team in Muse, office. In the first year alone, the team carried out five pieces of research Burma (Myanmar). (section 4.2). This strategic information has helped to support advocacy efforts and contributed to policy change, such as Ruili County’s reversal 3.2 Sustainability of a 20-year ban on NSPs. Further, project staff on both sides of the Although the Yunnan Cross-Border Project is scheduled to last only 2.5 border have been able to generate and share data that describes the years, from the outset the provincial and county teams have focused HIV epidemic and the spread of other blood-borne diseases such as on how to ensure that activities can continue in the long term. When hepatitis B and C in the area. selecting four project sites, the provincial team looked for counties that 3.4 Cross-border cooperation had existing project relationships across the border: for example, the Health Unlimited Project working in Yinjiang County and Kachin State Initial steps have been made to build cross-border cooperation at both and the previously mentioned relationship between Ruili County and the provincial and the county level. Ruili County and Muse are currently Muse. working on a cross-border cooperation framework (section 4.1), while the YNAB is currently formulating HIV strategies for each of the province’s In Ruili County the team works to the mantra ‘don’t start anything new’. border counties. Further, evidence and data sharing between HAARP NSPs have been set up in existing sites, including a language school and staff working in both countries exemplifies growing mutual trust across grocery store (section 4.3). This approach not only contributed to the the border (section 3.3).

4 While progress has clearly been made, cross-border cooperation is still largely aspirational. A lot of initiatives are coming from the Chinese side. While Burmese project staff have been responsive and supportive, Today, Han has 18 regular clients, particularly in Muse, capacity issues inevitably mean it will take longer mostly male, many of whom visit for Burma (Myanmar) to come on board. every day or two. Her clients wait until any shoppers have Box 2. Groceries and needles in Dengxiu village left the store before coming in to exchange their needles and syringes. When Han is not available, her son covers for her. Han Shuaizhan’s grocery store in Dengxiu village sits on the border of China and Burma (Myanmar). Since November 2009, Han has While the store’s secondary role offered more than just groceries; her store is also distributes is discreet, villagers are aware needles and best location for the program, it gained agreement of it. Not all approve, saying from the town leaders and Public Security department to operate that her work condones drug the site. taking. “I say to them that I’m not supporting drug use,” she Han initially opposed having the site in her store. “I didn’t want to get said. “This is disease prevention. It’s easier for me to answer them close to injecting drug users,” she said. “I have a son and was afraid because at first I had the same opinion and questioned why needles of the influence on him. But after a year there has been no negative should be distributed.” influence.” Han received training in needle and syringe disposal and distributing information, education and communication materials. She was then left to establish the program at the new site. Already familiar with the drug users in her village and the places they met to take drugs, she went to tell them that they could get clean needles from her without risk.

5 4. The Yunnan Cross- Box 3. Successful advocacy for needle and syringe programs: Border Project in action • focus on key policy-makers • cooperation between health care and law enforcement “The cross-border project trains people to show them that carrying bodies out AIDS control on one side of the border just isn’t enough. You • clear local evidence and shouldn’t just sit at home and cook for yourself.” success stories provided to support NSPs Duo Lin, Project Manager, Yunnan • qualified outreach teams 4.1 Cross-border capacity building • results used to further demonstrate the benefits of NSPs. Addressing policy issues • importance of cross border efforts. The NSP is a major component of cross-border services provided through the project. In 2007, Yunnan became the only province in China to legalise NSPs. This shift in policy was supported by the provincial Despite this great leap forward in policy, change has taken place more team implementing the HAARP and its preceding ARHP. slowly in practice. Until recently, Ruili County government doubted the The HAARP advocated for NSPs as part of a comprehensive approach need for, and effectiveness of, needle syringe distribution.. Further to HIV among people who inject drugs, especially in the border areas. evidence and training was provided to local governments in project MMT was the preferred intervention among people who inject drugs. counties to advocate for NSP and cross border services. The Yunnan The project presented data to the provincial government to demonstrate Cross-Border Project has analysed the advocacy process followed in that HIV was transmitted through sex and shared needles and that MMT Ruili County to document how to create an enabling environment for alone would not be enough. It was also made clear that one-sided HIV NSPs (Box 3). prevention efforts were insufficient and there was a need for effective Over two months, Zhang Miaoyun, chief of the Ruili AIDS Department, cross border cooperation. held regular advocacy meetings with the county government and law enforcement agencies. Using the analogy of a flood, she described

6 NSPs as another dam to hold back the spread of HIV. She acknowledged training in the Ruili detoxification centre and provision of antiretroviral that while NSPs and detoxification centres may appear to be mutually therapy to Burmese wives were all bold measures that they would not contradictory, they share the common goal of harm reduction and work have attempted without county backing. The Ruili AIDS Department together as part of a comprehensive response to drug use and HIV hopes that a cooperation framework with Muse City will enable it to prevention. Over 20 years after the first HIV case was detected in an further expand its coverage. injecting drug user in Ruili County, the county now supports a number of NSP sites along the border. Training and capacity building The provincial cross-border team has carried out three types of training Framework for cooperation and capacity building: The first annual Yunnan Cross-Border Project meeting was held in • training for law enforcement staff along the Yunnan border Kunming, Yunnan, in June 2010 with over 40 attendees from Burma • coordination meetings for project staff from Yunnan, Burma (Myanmar), (Myanmar), China, Laos and Vietnam. This meeting provided an Vietnam and Laos4 held in Kunming opportunity to share data and best practices, as well as to plan further • training for the new outreach workers selected by project counties. joint interventions.

At the provincial level in Yunnan, the government currently pays close A key focus of cross-border training is to explain why carrying out HIV attention to cooperation with its international neighbours. When interventions on just one side of the border is not enough. interviewed Zhou Hongmei, deputy director of the Administration Ruili County’s initial focus has been on building capacity among its Office of the Yunnan Provincial HIV/AIDS Prevention and Control project staff, cross-border outreach workers and staff from the Muse Bureau , expressed the hope that the Yunnan Cross-Border Project and HAARP EAP. To build up trust with its Burmese counterparts, Ruili County similar activities funded by the Global Fund and the UK Department for has held study visits on either side of the border. Burmese outreach International Development would pave the way for a future provincial workers have been invited for training along with Ruili’s outreach workers. policy on cross-border HIV prevention. Further, Ruili and Muse project staff have provided joint training on HIV In Ruili County, the Yunnan Cross-Border Project works with the Chinese and harm reduction in Ruili’s detoxification centre. and Burmese foreign affairs offices toward setting up a cooperation Ruili County’s work to build up local resources has been noted at the framework between the local governments of Ruili County and Muse . provincial level, and there is now interest in setting it up as a training The Ruili AIDS Department clearly understands that the success of the centre for comprehensive interventions, to share its experience with project to date would not have been possible without support from the county government. The new NSP sites along the border, Muse staff 4 While Laos is not formally involved in the Yunnan Cross-Border Project, it has been included in coordination meetings as a neighbour of Yunnan Province and a HAARP country partner.

7 other counties and countries. The Ruili AIDS Department is looking labelling and collecting syringes has so far been provided to outreach to expand its training to cover other migrant populations that are not workers in three counties, and collection began in October 2010. considered high risk, in particular Burmese citizens travelling to China to It is worth noting that the Yunnan provincial team has carried out further work in the hospitality industry. strategic research into cross-border populations through the China 4.2 Cross-border research and strategic information HAARP CP. This research has surveyed epidemiological and behavioural factors in other high-risk cross-border populations such as sex workers Cross-border project research is contributing to a bank of knowledge and long-distance truck drivers. that both captures best practice and provides evidence to support future NSP interventions and cross-border activities. Box 4. Harm reduction knowledge among anti-narcotic police

Research has included: Ninety-three anti-narcotic police in Cambodia, Burma (Myanmar) and • measuring improvements in harm reduction knowledge among the Vietnam completed a survey that assessed knowledge of HIV and harm anti-narcotic police in Cambodia, Burma (Myanmar) and Vietnam reduction and attitudes to people who inject drugs. The questionnaire was • comparative research into Chinese and Burmese injecting drug users completed before the police attended HAARP training. in Ruili County’s detoxification centre • analysis of HIV, hepatitis B and hepatitis C co-infection among • 73.9% perceived drug users as the ‘victim’ of drugs Burmese and Chinese injecting drug users • 61.5% support mandatory detoxification for drug users • research into HIV incidence among Chinese and Burmese injecting • 59.3% agree with needle exchange drug users covered by the NSP • 39.6% support MMT. • comparing high-risk behaviour among people who inject drugs in three Burmese and Chinese counties. HIV-related knowledge was low in all three countries, but attitudes to harm reduction are slowly improving. These findings show that further training is The Yunnan Cross-Border Project has taken a different and rather creative needed to strengthen HIV knowledge and understanding of harm reduction. approach to measuring HIV incidence. Rather than drawing blood from Another highlighted need is training on occupational exposure. a target group, the project tests the blood found in used syringes, as this is sufficient to test for HIV and hepatitis B. Real data, real cooperation This method saves time and money but requires that syringes be carefully Prior to the Yunnan Cross-Border Project, staff in the Ruili AIDS labelled to ensure that only one syringe is tested per client. Training in Department had met with their counterparts at the Muse EAP in Burma

8 (Myanmar). These meetings were, however, largely superficial. While Box 5. Teaming up to increase coverage in Nongdao participants were able to discuss general impressions and activities, they were unable to share epidemiological data. These restrictions made it difficult to assess whether interventions were successful or if The Nongdao village clinic was set up using government funds in they targeted the right populations. May 2007 and has been operating as an NSP for HAARP since June 2010. Integrating the NSP site into an existing clinic avoided any This restriction has impact beyond the county level. Because only additional setup costs. It built on the service provided by the clinic’s provincial government is permitted to issue epidemiological data, doctor, Qiu Zhengxian, who had already been selling clean needles experts in local centres for disease control and prevention do not have to about 10 drug users on a regular basis. timely access to data, nor can they use findings to publish research papers. When Qiu began operating the NSP from the clinic, she informed Through the project, the HAARP Yunnan team has actively encouraged her existing clients that needles the creation and dissemination of real data between counties across and syringes were now available borders. Current data and the nature of the epidemic can now be free of charge and asked them discussed in local cross-border meetings, and the provincial team to pass on the message. Despite encouraged both sides to share information as they can trust each other. the new free service, Qiu still In addition to enabling project activities that are better targeted and has few clients beyond her old more informed, this strategic research builds a firm evidence base to group of about 10. support future cross-border interventions. To expand NSP coverage, Qiu 4.3 Cross-border service provision recruited Yan Liang, an ethnic Dai injecting drug user and one Needle and syringe program of her clients from the village. Ruili County has set up eight NSP sites along the border. When choosing Yan now works as an outreach sites, Ruili project staff had two main criteria: (i) the sites needed to be worker for the clinic, distributing needles and syringes; information, accessible and (ii) they did not want to establish any new facilities but, education and communication materials; and condoms. Working in instead, use existing services and sites. This latter condition has led to the field he has increased the site’s coverage to over 50 clients. the creation of some rather original NSP sites, including a grocery store in the village of Dengxiu and a language school in Jie Gao.

9 By integrating NSP sites with existing businesses and clinics, Ruili staff less extensive in Ruili than in other counties. These low figures need to avoided spending the time and funds needed to build a service centre be addressed and improved as the project goes into its second year. from scratch. Looking for existing sites to house the NSPs also meant The limited distribution of IEC materials can be explained by language project staff could focus on selecting the best location for extending barriers. Ruili has so far received and distributed IEC materials only in their coverage. As the sites’ existence does not rely wholly on project Mandarin, despite the project’s target audience being Burmese drug funding, the sustainability of their services is improved. users whose native language is either Dai or Burmese. The outreach Another notable difference in Ruili’s service provision is that its outreach workers explained that they pass on safe-injecting and HIV-prevention workers are not drug users. Ranging from small business holders to information verbally to those who cannnot read Mandarin, but recognised doctors, the outreach workers were selected because of their location that not having bilingual materials was restricting their potential audience. and nationality: all are either Burmese citizens or Dai, the largest ethnic One outreach worker pointed out that many older people, both in Ruili minority in Muse and Ruili. The Ruili AIDS Department chose Burmese- and across the border, speak only Dai. Consequently, if drug users take or Dai-speaking outreach workers to overcome language barriers when leaflets home their families may be unable to read it. targeting Burmese clients. Translated versions of IEC materials are currently in production at the The decision to assemble a team of outreach workers who did not provincial level. In the interim, Mao Chunling, who manages the NSP site inject drugs was an experiment. The project team was interested to see at the language school in Jie Gao, has approached HAARP staff in Muse if these outreach workers would suffer less discrimination in the local and requested copies of their Burmese language materials (Box 6). This community. While cross-border outreach workers appear to have had a is a good example of the resourcefulness of the outreach workers and successful first year, some have had to work hard to contact their clients project staff working in Ruili. and earn their trust. In response to this challenge, Qiu Zhengxian, the doctor who runs the NSP at the Nongdao village clinic, has recruited Referrals one of her clients as an additional outreach worker who acts as a roving The referral system for cross-border clients in Ruili has not been without distribution point to expand the clinic’s coverage (Box 5). its challenges, but some key achievements have been made. In particular, MMT has now been made available to 96 Burmese citizens in Ruili County, Condoms and information, education and communication and 21 clients have been referred for voluntary counselling and testing. materials In April 2010, China revoked its ban on HIV-positive people entering In addition to distributing needles and syringes, all NSP sites provide the country. This change in policy has removed an additional barrier to condoms and information, education and communication (IEC) cross-border clients trying to access HIV services in China. For example, materials. The distribution of condoms and IEC materials is noticeably while treatment to prevent parent-to-child transmission of HIV is offered

10 free of charge to Burmese women, referring Box 6. Local people, local services: Harm reduction services in Jie Gao them for this service across the border was problematic. Mao Chunling moved to China from Burma (Myanmar) 12 years ago. Recently, the Ruili AIDS Department began After training as a nurse in Luxi she returned to the Jie Gao Free Trade to offer antiretroviral therapy to HIV-positive Zone on the border with Burma (Myanmar) to set up a language school. Burmese wives of Chinese drug users. This It was here that she encountered the Ruili AIDS Bureau. The premises is a bold move, as non-Chinese citizens are that Mao selected for her school had been identified by the bureau as ineligible for these services and the change in an ideal location for a cross-border NSP. That the site was occupied by policy has yet to be sanctioned by either the a bilingual nurse made it even more attractive. provincial or the national government. The Yunnan Provincial HIV/AIDS Prevention and The NSP was set up in Mao’s language school at the end of 2009. Control Bureau is pushing for national funding While she does not appear fazed, the uptake of the service has been to extend antiretroviral therapy to Burmese overwhelming. In the first couple of months she had fewer than 20 citizens, but the size of the necessary budget clients, but by October 2010 she had 150 clients, which she believes includes nearly all of Jie Gao’s injecting drug users. This rapid growth in coverage illustrates the benefits of using local people and long-term nature of the investment mean a to provide outreach services. decision may take some time. ”I grew up here”, she explains. “People know me, and I know the local drug dealers. So I went to Ruili project staff wanted to act more quickly. the dealers and asked them to tell their buyers that I had clean needles and syringes. I know the Capacity for providing antiretroviral therapy in drug users trust their dealers.” Muse is weak, as only five of the ten people who qualify receive it at the government hospital. Mao has made good use of her local connections. Having worked as a Burmese translator for Jie Referrals can also be made to Médecins Sans Gao’s public security officers, she made sure they were informed of her additional outreach work. Frontières in Burma (Myanmar), but, again, When in need of Burmese IEC materials, she crossed the border to Muse EAP and requested capacity is limited and services are far away. copies of their leaflets. Later, as demand for needles and syringes rose, she relocated the site to a nearby motorbike packaging warehouse near a ‘shooting gallery’. The warehouse is managed by With the support of the county government, a friend, who also helps Mao with her outreach work. Ruili has extended the service to Burmese wives living in China, regardless of whether they hold Overall, Mao’s outreach work is a prime example of the resourcefulness that is encouraged in Ruili a Chinese identity card. project staff.

11 not been of use in Ruili County, where the local language is Dai. In other 5. Challenges and areas for counties in Yunnan and Burma (Myanmar), Jingpo is more likely to be the lingua franca. Similarly, limited condom distribution in Ruili County may improvement be improved if local and rural cultural norms are addressed. In an ethnic group that views extramarital sex as deeply taboo, unmarried men, or those away from their wives, are unlikely to ask an outreach worker for 5.1 Equal participation condoms. More discreet distribution measures should be investigated. Cross-border cooperation is still somewhat nascent, with most activities 5.4 Gender awareness generated on the Chinese side. While Burma (Myanmar) is beginning to Most clients in Ruili County are male. While this may reflect, for the most link up with activities on the other side of the border, developing equal part, current infection and drug use rates, local and provincial teams levels of engagement will take time and effort. need to ensure that strategies are in place to reach females who inject 5.2 Improvements in service delivery and referral drugs and the female sex partners of injecting drug users. Testing and prevention of parent-to-child transmission proved to be 5.5 Selecting and training outreach workers very challenging while the Chinese border ban on HIV-positive people Ruili County has piloted the exclusive use of outreach workers who are remained in effect. Now that this law has been revoked, referral remains not injecting drug users. It is worth further investigating how successful problematic. Non-Chinese citizens do not qualify for many services and this has been. While some outreach workers, such as Mao Chunling in capacity in Burma (Myanmar) remains weak. The Chinese government is Jie Gao Free Trade Zone, have rapidly built up a client base, others have reviewing whether antiretroviral therapy can be offered to non-Chinese struggled. For example, Qiu Zhengxian in Nongdao village has employed citizens, but it may take some time to reach a final decision. The limited a male drug user to provide outreach services in the field, as clients are distribution of condoms and IEC materials also needs to be addressed. reluctant to visit her clinic. All the outreach workers interviewed had 5.3 Emphasis on the local context recruited additional outreach workers to cover them in their absence or, in Qiu’s case, to extend coverage. It is important that any new recruits Each of Yunnan’s border counties and their neighbouring counties in receive official training at the provincial level. Further, safety training Burma (Myanmar), Vietnam and Laos have distinctive ethnic groups, needs to be emphasised, as at least one of the outreach workers has cultures and languages. All of these factors need to be taken into gone to work in the field unaccompanied. account when delivering services. Centrally produced IEC materials have

12 6.2 Importance of flexibility 6. Lessons learned and When setting up any project it is important to identify existing service best practice in cross- delivery gaps and address them. Yunnan project staff targeted injecting drug users from Burma (Myanmar) with initial cross-border activities border working because they were underserved and harder to reach. Throughout the Yunnan Cross-Border Project the focus has been on less input and more output. When identifying project counties, the provincial China operates within a very specific political and cultural context and team looked for existing project mechanisms and relationships to build the situation across the border in Burma (Myanmar) is equally distinct. In on, such as the Health Unlimited Project at the Longchuan County border, addition, circumstances vary between Burmese states and among each and interaction among border police. of Yunnan’s border counties. As such, many of the methods employed Similarly, the Ruili AIDS Department has made good use of existing in Ruili must be understood in their specific context. That said, there are resources and networks. The NSP at the grocery store in Dengxiu some general lessons that can be drawn from activities in Yunnan and village was initially meant to be located in Burma (Myanmar). When Ruili and used to inform future cross-border work. the department was unable to secure permission for the NSP from the 6.1 Using regional programs to facilitate cross-border work Burmese police, it set up the site directly across the border. Setting up government-to-government cooperation frameworks can 6.3 Importance of strong local knowledge take a long time, but, within a regional program, work across borders Employing local staff and outreach workers plays an important role can be set up quickly. Where regional programs such as HAARP have in ensuring the success of cross-border activities. The achievements already been ratified nationally, gaining multi-level approval for cross- of the Ruili team and outreach workers such as Mao Chunling were border work can be easier to achieve and government support can help underpinned by an understanding of who to talk to, where to locate instil confidence. In Ruili and Muse the rapid set-up of services owed a services and the overall local context. As previously mentioned, cultural lot to existing HAARP sites on both sides of the border. In contrast, in issues such as sexual norms and risk behaviour among ethnic minorities Hekou and Yinjiang counties of Yunnan Province, the lack of a HAARP and rural communities must be taken into account to ensure that service counterpart site across the Vietnamese and Burmese borders accounts provision is relevant and appropriate. for some of the difficulties local project teams faced. The backing of the local authorities is critical. The Ruili AIDS Department freely admits that without this backing it would not have been able

13 to implement so many bold measures, such as bending the rules on Once the Ruili model for cross-border work has been fully developed, this antiretroviral therapy for non-Chinese citizens. Similarly, the Ruili AIDS evidence can be used to advocate policy change and the mechanisms Department was aware that previous NSPs had failed in Ruili because employed can be rolled out at other Yunnan sites. Public Security was not on board, so the project focused advocacy 6.6 Politics and security efforts on ensuring police support. All new programs and activities need to take into account the delicate 6.4 Need for advocacy and education first regional power balance and ever-changing political situation. During The previous work done through the ARHP in China and Burma (Myanmar) the visit for this Positive Practice study, entry to Burma (Myanmar) was facilitated the rollout of the Yunnan Cross-Border Project and harm not possible because foreign consultants were barred from the country reduction work in general. Yet, a gap remains between policy changes in the run-up to elections. and actual implementation. For example, Yunnan Province’s NSP policy It is important to be aware of, and continue to monitor, sensitivities in was in place long before the Ruili County government agreed that sites border areas, in particular where there is conflict or local insurgents. could be set up. Importantly, this situation may differ from county to county along a There is a need to identify local change agents and focus advocacy efforts border. Again, this is where strong local knowledge is needed. on them. For example, in Ruili it was necessary to get Public Security to Security is also an issue, as borders are often militarised. This can affect accept NSPs. Education plays an important role in increasing the uptake the safety of project staff and interfere with service delivery, for example of services, as, for example, injecting drug users must understand why police in Muse refused to allow Ruili staff to set up an NSP site on their they need to use clean needles before NSP sites are set up. side of the border. 6.5 Research into practice Whereas ARHP focused on changing minds, HAARP and the Yunnan Cross-Border Project have provided an opportunity to put ideas into practice and generated evidence of what works.

The cross-border project has generated a huge amount of strategic research results that, unlike data produced by centres for disease control and prevention, can be disseminated and published. Being able to talk about current epidemiological data and behavioural studies enables a more effective response on both sides of the border.

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